| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
389 |
389 |
$10K |
| D0274 |
Bitewings - four radiographic images |
165 |
165 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
165 |
165 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
267 |
267 |
$3K |
| D1351 |
Sealant - per tooth |
62 |
18 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$1K |
| D1206 |
Topical application of fluoride varnish |
27 |
27 |
$717.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$606.68 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$138.70 |